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How Medicare "Star Ratings" can be Improved to Help Seniors

By: Erica Pham, Deputy General Counsel, Clover Health

Ratings undoubtedly influence decision-making. From choosing a restaurant on Yelp, to finding the best helper on TaskRabbit, ratings help us understand the quality we can expect and ensure that businesses are held accountable for the service they provide.

But when scores don't accurately reflect reality, their influential role in decision making can present a problem. Unreliable rating is not just irrelevant, but potentially harmful; in the worst case it can incent businesses to make decisions solely based on how to improve their public rating, rather than what's best for consumers.

In healthcare, we see ratings across the system, from the notion of “top-rated doctors” and “most effective treatments,” to how a health insurance plan serves its members. These are critical tools for consumers to get them the quality care they deserve and make the choices that are right for them.

For the Medicare population, measuring quality comes through the Star Ratings Program, a five-star rating system to measure beneficiaries' experience with their health plans and to help consumers evaluate and compare Medicare Advantage plans. The Star Ratings Program has become a critical consumer tool to help differentiate Medicare Advantage plans.

In that spirit of continuous improvement, we believe now is the time to enhance the Star Ratings system and to link metrics far more directly to patient health and quality outcomes. Currently, the Star Rating puts too much emphasis on process, encouraging plans to focus on specific operational components rather than pursuing interventions that create the best health outcomes. This focus on process can result in potentially misleading ratings, leading consumers to choose plans that may not be right for them.

Here is what Clover is recommending to help make the Star Rating live up to its stated purpose:

1) Link Ratings to Outcomes: Ratings should explicitly reflect a focus on outcomes to encourage innovation. For example, Clover uses our data analytics program to detect when our members are at risk for hospitalization, and in most cases, can prevent that hospital admission through early intervention. But, because admissions is not a measure in the current ratings system, consumers cannot select plans measured by such prevention outcomes. Now is the time to incentivize health plans to provide healthier outcomes and to allow consumers to choose based on those outcomes.

2) End Survey-Based Methods for Clinical Adherence Metrics: We support the elimination of survey-based methods for clinical adherence metrics for which the health plan can provide evidence and documentation. We believe clinical interventions should be measured with clinical data across all measures to eliminate recall bias and other common self-reported complications.

3) Recognize Differences in Underserved Communities: People from underserved communities face a variety of barriers, including poverty and systemic racism, that meaningfully affect their health outcomes. The current ratings do not sufficiently address these differences. We see this first hand at Clover, as we have roughly twice the number of people of color as the average Medicare Advantage health plan and a substantially higher population of members who fall into lower income brackets. Like other health plans supporting these communities, we do not receive additional incentives to help us close these equity gaps. Rather, we lose out on substantial Stars payments, penalizing us for directly addressing inequities and giving us fewer resources to close care gaps. We are not the first to point out this problem. Though we have no intention of changing the communities we serve along with our pursuit of equitable access for all, the current rating system's unintended consequence of pulling resources away from those who most need them is seriously flawed.

4) Factor in Broad Access to Providers: CMS should factor in the type of plan network when evaluating network-related measures. For example, open PPO plans offer expanded access by allowing seniors to choose any medical provider. As a result of this focus on choice, PPO plans cannot meaningfully control the wait times, ease of getting care, and other process measures for non-network doctors. The Star Rating methodology should account for the benefits of increased choice by adjusting measures based on plan type.

Putting members first is in our DNA at Clover. We continue to support CMS's efforts to ensure Medicare beneficiaries get the quality care they deserve and to ensure Star Ratings capture the full story of health organizations like Clover.

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Last Updated: 1/11/2019

Clover Health is a Preferred Provider Organization (PPO) and a Health Maintenance Organization (HMO) with a Medicare contract. Enrollment in Clover Health depends on contract renewal. You must continue to pay your Medicare Part B premium. For plans that provide drug coverage, the formulary may change during the year. Out-of-network/non-contracted providers are under no obligation to treat Clover members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Medicare beneficiaries may also enroll in Clover Health through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

Disclaimers

This information is not a complete description of benefits. Call 1-888-657-1207 (TTY 711) for more information. Limitations, copayments, and restrictions may apply. Plan performance Medicare Star Ratings are assessed each year and may change from one year to the next. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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